June 6, 2016

Pulse on ​Family Medicine: Primary Care Policy Update

Update on Medical Assistance in Dying

On June 6, 2016, the Carter v. Canada (Attorney General) decision comes into full effect, which means physicians are legally permitted to assist in the death of a competent and consenting adult with a grievous and irremediable medical condition who is suffering intolerably.

What is happening with the legislation?

Bill C-14 has been passed by the House of Commons federally and the Senate has voted to adopt C-14 in principle and has sent it to the Senate's legal committee. With no legislation currently in place, the unanimous Supreme Court decision in Carter v. Canada means that it is no longer a criminal offence for a physician to provide medical aid in dying for a patient who requests assistance and who meets the eligibility criteria. It is expected that the provincial legislation will align with the federal legislation.  
 
While there is no new federal legislation as of yet, there is guidance in place that outlines eligibility criteria and safeguards. The College of Physicians and Surgeons of Ontario (CPSO) has issued Physician-Assisted Death (Policy #4-16), that complies with the Supreme Court of Canada's February 2015 decision in Carter v. Canada. It outlines the professional and legal obligations that apply to physician-assisted death, eligibility criteria for patients, and guidance for physicians on practice-related elements.
  
The CPSO guidance is the primary document for all physicians in Ontario and the CPSO's Physician Advisory Services is available to discuss any questions (1.800.268.7096 ext. 606 or 416.967.2606). The public and patients can also address questions to the CPSO at 1.800.268.7096 ext. 603.

While not required by the Supreme Court, patients and health-care providers are encouraged to seek further clarity about how the Supreme Court's decision applies to their particular circumstances by bringing an application to the Ontario Superior Court of Justice. 
 
Once the federal legislation has passed, the CPSO guidance may change. This will be flagged in a follow-up communication. Physicians are also encouraged to seek legal counsel through the Canadian Medical Protective Association (CMPA) until the legal framework is approved. 

What does this mean for you in your practice?

In the days and weeks ahead you may see an increase in questions from patients about medical assistance in dying. If this is the first time a patient has raised end-of-life wishes, it is important to engage the person and their family first in a broader discussion about palliative care and end-of-life care support. As you know, there are palliative and end-of-life options that address pain, symptom management and issues of isolation and fear of dying.
 
For many people, a palliative approach to care can help manage their medical and psychosocial concerns. For patients who still want to pursue an assisted death, the CPSO's  Guidance outlines the necessary process for you to follow.
 
The Ministry of Health and Long-term Care (MOHLTC) announced today a clinical referral service to support physicians in making an effective referral for consultation and assessment of individuals requesting assistance in dying is being developed. The service is intended to support a physician who needs to refer their patient to another physician willing to support the patient's request. The MOHLTC is issuing more information directly to physicians. You can also contact the Clinical Referral Service directly for more information, to register or to request referral support (maidregistration@ontario.ca / 1.844.243.5880). This information is for clinicians only and not for the public. 
  
This is a challenging time for patients and physicians as Canadians navigate these uncharted waters. Many organizations, including the OCFP, are in the process of developing education and support resources to assist you in supporting your patients, whether that is to be able to address questions or seek a referral, or work with the patient directly through the process. Please visit the OCFP online resources section for links to available resources. New resources will be added as they come available.
 
We know that as we wait for legislation and further clarity from the federal and provincial governments, Ontario family physicians will continue to work in partnership with their patients to ensure they receive high-quality palliative and end-of-life care, and that their treatment wishes in this regard are valued and respected.   

The OCFP is committed to working with hospitals and other health-care partner organizations to ensure that medical assistance in dying, and palliative and end-of-life care, is delivered in a coordinated way across the province. We are committed to offering members as much ongoing support and guidance as possible in this evolving and highly complex environment. We will continue to be in touch as this evolves.

Links and Resources

These and other resources can be found on the OCFP's website.